Recovery Resolutions Investigator (SIU Empire) - San Juan, PR
UnitedHealth Group
- San Juan, PR
- Permanent
- Full-time
- Assist the prospective team with special projects and reporting
- Initiate phone calls to members, providers, and other insurance companies to gather information.
- Investigate and/or resolve all types of claims for health plans, commercial customers, and government entities.
- Triage claims data to send for medical coding review.
- Collaborate with clinical coding consultants for purposes of educating and communicating to provider
- Review medical records to gather relevant facts to drive investigations and communications.
- Conduct data mining and analysis for potential flags.
- Communicate clear rationale for investigation processes and outcomes to Client, Regulator and stakeholders (referrals and OP).
- Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance.
- Utilize appropriate systems to monitor and document status of investigations.
- Monitor investigation status throughout the process.
- Collaborate with a variety of external sources to identify current and emerging patterns and schemes related for FWA.
- Use pertinent data and facts to identify and solve a range of problems within area of expertise.
- Generally, work is self - directed and not prescribed.
- Work with less structured, more complex issues.
- Serve as a resource to others.
- An associate or bachelor's degree in criminal justice or a related field
- 5+ years of experience in the healthcare field working in fraud, waste and abuse investigations and audits, (or) five years of insurance claims investigation experience or professional investigation experience with law enforcement agencies, (or) seven years of professional investigation experience involving economic or insurance related matters
- Experience with one or more of the following:
- Claim processing
- Provider demographic information
- Insurance billing practices
- Experience using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, etc
- Working experience with Microsoft Tools: Microsoft Teams (join meetings and trainings), Microsoft Power Point (prepare presentations), Microsoft Word (creating memos, writing), Microsoft Outlook (setting calendar appointments, email) and Microsoft Excel (creating spreadsheets, filtering, navigating reports)
- Available to work (40 hours/week) Monday - Friday. Flexible to work any of our 8-hour shift schedules during our normal business hours of (6:00am to 6:00pm EST). It may be necessary, given the business need, to occasionally work mandatory overtime, holidays or weekends
- English proficiency
- Nursing degree
- Coding experience
- Managed care experience
- Claims processing experience
- Medical record familiarity
- Experience in healthcare claims investigations
- Experience in lean and/or six sigma methodology
- Organization affiliation and/or certification:
- Association of Certified Fraud Examiners (ACFE)
- Certified Fraud Examiner (CFE)
- National Health Care Anti-Fraud Association (NHCAA)
- Accredited Healthcare Fraud Investigator (AHFI)
- International Association of Special Investigation Units (IASIU)
- Certified Insurance Fraud Investigator (CIFI)
- Certified Insurance Fraud Analyst (CIFA)
- Certified Insurance Fraud Representative (CIFR)